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Fraud & Abuse Management
 
Sanovia Claims·LogicSM provides fraud and abuse support services; or will manage fraud and abuse activities for the client and is a critical component of a well managed pharmaceutical program. Sanovia aggressively tracks down fraud and abuse by looking at the entire program, taking the claim data produced by your Claims Processor or PBM and convert it into useable information.
 
Patient Utilization Trends
 Physician Trends
 Pharmacy Trends
Average
Prescription
Utilization
Average
Prescription Cost
Average per
Patient Cost
Disease Management Opportunities 		Formulary
Compliance
Percent DEA,
DAW Brand vs.
Generics Quality Indicators
 Targeting
Network Issues
Percent DEA,
DAW Brand vs. Generics
Billing Patterns
for Fraud and
Abuse
 
The intuitive application provides cross-sectional views of claims data, calculations for data normalization and statistical analysis that can be used to target issues, interventions and potential areas for investigation. The unique reporting functionality will allow drill down to view and analyze multiple layers of data – from top level summary to full claim detail.
 
Several trends underscore the importance of monitoring claims and ensuring network integrity:
1. The GAO and Congressional Budgetary Office estimate that healthcare fraud and abuse costs 10% or $100 billion annually, severely undermining efforts by payers to raise care standards while containing cost to patients.

2. Drastic increases in utilization, record member enrollment and the dynamic state of the industry have complicated the ability of Health Plans to ensure claims are correctly processed and reimbursed.

3. The recent popularity of expensive specialty and injectable pharmaceuticals as well as home based therapies as an alternative to inpatient care.
 
PATIENT
PHYSICIAN PHARMACY
 
Fraud & Abuse Management Programs
Pharmacy Claims Review
PBM Review
Fraud & Abuse Investigation
Infusion Audits
Specialty Audits
Patient Restriction Programs
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